Registration Form & Liability Waiver & Photo Release
City, State, Zip____________________________________________________Home Phone (____)-____-____
Mother’s Name_____________________________________________________Cell Phone (____)-____-____
Father’s Name______________________________________________________Cell Phone (____)-____-____
Emergency Contact_________________________________Relation______________Phone (____)-____-____
Physician Name:________________________________________________________Phone (____)-____-____
MEDICAL CONDITIONS WE SHOULD BE MADE AWARE OF?______________________________________________
How did you hear about All-Star Academy Gymnastics?_________________________________________________
Assumption of Risk, Release of Liability Waiver, Photo Release, Medical Authorization
As Parent/Legal guardian or Non-Custodial Adult of student/s name above. I hereby consent to his/her participation in All-Star Academy Gymnastics programs and fully understand Items A thru E below.
A) I understand and recognize that severe injuries, including permanent paralysis or death can occur in sports or activities involving height or motion, including gymnastics, cheerleading, dance, tumbling and other related activities. I understand that it is the intent of All-Star Academy Gymnastics to provide for the safety and protection of my child, while participating and in consideration for allowing my child to use these facilities. I hereby forever release All-Star Academy Gymnastics, its officers, employees, instructors, respective officers, directors, contractors, volunteers, Next Level Academy and any employees associated with Next Level Academy, from all liability resulting from damages or injuries incurred as a result of participation including those resulting from acts of negligence.
B) I also hereby give permission to allow trained medical professionals to administer emergency medical treatment to my child, should an accident or sickness occur in my absence.
C) I am aware that individual and group photos and videos are taken from time to time and in consideration for my child’s participation I hereby grant my permission for my child’s recorded image or video to be used for marketing, advertisement or other publicity as deemed appropriate by All-Star Academy Gymnastics.
D) I have read and understand this ASSUMPTION of RISK, LIABILITY WAIVER and PHOTO RELEASE and is signed voluntarily to its content and intent herein.
E) I understand that all payments are non-refundable (credit only) and any credit not used within one year from the time payment was received will be forfeit.
I understand that if I am signing as a Non-Custodial Adult I have been given permission by the Parent or Legal Guardian of the Student/s listed above and fully understand items A thru E above.
Parent/Legal Guardian or Non-Custodial Adult Signature______________________________________________________________________Date_______________
**Please print this form and fill it out to bring with you to your first class/practice.**
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